MAINE DEPARTMENT OF EDUCATION

APPLICATION FOR EDUCATIONAL APPROVAL RENEWAL

W Z

COMPUTER

RUN DATE

1. NAME (First, MI, Last, and optional suffix such as Jr., III) / 2. Social Security Number
- - / 3. Other name(s) under which
Your records are filed / DATE
4. Mailing Address / 5. EMAIL Address / 6. City or Town / 7. State / 8. Zip Code
9. Home Phone / 10. Sex
____ Male
____ Female / 11. Date of Birth
/ /
mo. day yr. / RETURN TO: DEPARTMENT OF EDUCATION
CERTIFICATION OFFICE
23 STATE HOUSE STATION, AUGUSTA, ME O4333-0023

Have you been continuously employed and properly credentialed over the last five years in a Maine school system, excluding vacation and sick leave days? Note: This does not include coaching or substitute teaching. If yes, your fee is $15. (Your application must be to our office within 30 days of the expiration of your current approval or the additional $24 fee applies).

YES _____ NO _____

If yes, where: School Unit* ______from ______to ______

School Unit*______from ______to ______

*If a private school, please submit verification from the headmaster.

If you have not been continuously employed and properly credentialed over the last five years in a Maine school system, please submit an additional $24 fee ($39 total) to update your criminal history record check.

THE FOLLOWING QUESTIONS MUST BE ANSWERED:

1.  Have you ever been convicted of ANY crime? ____ YES ____ NO

(Notes: DUI/OUI must be included; they are not considered minor traffic offenses. If you have been convicted of

a crime and answer “no”; this is grounds for revocation, suspension, denial, and/or nonrenewal of approval.)

2.  Have you ever had any occupational or professional license or credential suspended or revoked in any state, or voluntarily surrendered an occupational or professional license or credential? ____ YES ____ NO

3.  Have you ever resigned following allegations of physical or sexual abuse? ____ YES ____ NO

If the answer is yes to any of the above, please attach a detailed explanation and, if necessary, required court documents.

I hereby declare or affirm under penalty in the law for unsworn falsification that this application, and any supporting documentation provided in support of this application, contains no willful misrepresentations or falsifications and that the information given by me is true, accurate, and complete to the best of my knowledge and belief, and so far as based on information and belief, I believe the information to be true. I understand that my answers may be verified and that I may be declared ineligible for certification and subject to civil or criminal penalties if there are any misrepresentations.

I authorize the Dept. of Education to charge the applicable fees for this application:

M/C ___ VISA ___ EXPIRATION DATE ______CREDIT CARD NUMBER ______

SIGNATURE OF APPLICANT ______DATE ______

DEPT. USE
ONLY / C

EFC-300-CR REV 2/16